Brighton Health Plan Solutions, LLC

About the Role BHPS provides Utilization Management (UM) services to its clients, ensuring high-quality, clinically sound decision-making. The Clinical Appeal and Grievance Nurse is responsible for conducting daily clinical and benefit reviews in a quality-focused, production-driven environment. The position reports directly to the Clinical Appeal Manager. Note: This job description is not intended to be an exhaustive list of duties. Responsibilities may evolve or change at any time, with or without notice. This is a remote role. Primary Responsibilities - Independently review and analyze pre and post service medical necessity and benefit appeals, post-service clinical claim disputes, and quality of care grievances. - Utilize member-specific benefit information, nationally recognized clinical criteria, and internal policies and procedures across multiple care disciplines, including, but not limited to, Inpatient Acute, Post Acute, Outpatient, Specialty Pharmaceutical, and Durable Medical Equipment - Prepare and present cases to internal Medical Directors and external Independent Review Organizations (IROs) for timely and accurate decisions - Ensure strict adherence to Appeals and Utilization Management (UM) processes and regulatory and accreditation requirements from intake through case closure. - Prioritize caseload and other assigned duties to meet clinical accuracy expectations and turnaround time requirements - Accurately enter case details in medical management platform - Collaborate with team members and other departments to achieve exceptional results and drive continuous improvement Essential Qualifications - Active and unrestricted RN or LPN license; must maintain licensure throughout employment - Minimum of 5 years’ experience in Clinical Appeals and Grievances within a managed care or payor setting - Minimum of 5 years’ clinical experience across various care settings (Inpatient Acute, SNF/LTAC/ARU, Outpatient, DME, Complex Care) - Strong understanding of UM/Appeals regulatory guidelines including URAC, NCQA, and ERISA - Proficiency in Clinical Appeals, Utilization Review, and Grievance processes including benefit interpretation, contract language, and medical policy application - Excellent written and verbal communication skills - Proficient in Microsoft Office Suite (Outlook, Word, Excel, PowerPoint). - Ability to work independently with exceptional accountability - Adaptability to a fast-paced and evolving environment. - Preferred experience in a Third-Party Administrator (TPA) setting - Preferred coding certification About At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com

About the Role Brighton Health Plan Solutions is seeking an experienced Manager of Provider Compliance to lead and oversee the investigation and resolution of provider disputes related to the No Surprises Act. The Manager of Provider Compliance is responsible for directing and reviewing all determination responses to ensure full compliance with established No Surprises Act guidelines and regulatory requirements. This role provides leadership and subject matter expertise to the Provider Compliance team, ensuring consistent, accurate and timely outcomes. The ideal candidate will be skilled in healthcare claims processing, including both professional and facility claims, and well as deep experience in healthcare provider contract negotiation. This is a remote position. Primary Responsibilities - Oversee all aspects of the No Surprises Act to ensure ongoing regulatory compliance. - Provide strategic oversight and thorough review of QPA claims, negotiations and agreements, and Independent Dispute Resolution (IDR) determinations. - Conduct and guide advanced claim research including professional, facility and ancillary claims. - Lead provider contract research, including rate analysis and negotiation communications. - Assist in interdepartmental communication to guarantee high quality and timely expedition of requests. - Guide and monitor Continuity of Care process and customer-specific communication to ensure regulatory alignment. - Support provider directory accuracy initiatives to strengthen data integrity and compliance. - Maintain tracking systems and dashboards to deliver ongoing reporting and actionable insights to executive leadership team. - Address complex, unstructured issues using conceptual and analytical problem-solving skills. - Identify trends and contribute strategic recommendations to enhance customer experience, improve productivity and reduce operational risk. - Drive process and system enhancements to align with evolving regulatory requirements, using NSA outcomes and data analysis to inform decision-making. - Maintain broad knowledge of MagnaCare’s client products and services. Essential Qualifications - Ability to maintain a professional demeanor under pressure. - Capable of managing multiple complex issues. - High School Diploma or GED diploma; Bachelor Degree preferred. - Strong knowledge of the No Surprises Act. - Ability to meet expected production standards and government mandated timeframes. - Strong knowledge of provider contracts, medical terminology, payment policies and procedures, and professional and facility claims processing. - Advanced analytic abilities. - 3+ years computer medical billing and/or claims adjudication systems experience. - 1+ year provider contracting negotiation experience. - Previous experience handling appeals and grievances a plus. - Excellent written and oral communication skills. - Interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required. - Effective interpersonal skills, including the ability to promote teamwork. - Proficient in Microsoft Office Suite- specifically Microsoft Word and Microsoft Excel. - Ability to maintain a professional demeanor under pressure. About At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com

About The Role Brighton Health Plan Solutions, a full-service health plan administrator, is looking for a part-time board-certified physician with interest and experience in managed care utilization and case management to support our team of nurses, social workers, and coordinators. You will be a leader of the team making medical necessity and benefit coverage determinations and provide support and guidance to the case management programs. You have a passion to make healthcare more effective and affordable. The position can be remote, or on-site in our New York office. The Medical Director will be responsible for providing support for our Commercial and Worker’s Compensation self-funded clients seeking cost-effective resolution of their members’ claims. Your interest and help leading and developing our team and maturing the program only makes the opportunity more rewarding. We have been in business for 25 years and leading by example you will help create a culture focused on service, support of quality healthcare service, and medical cost containment for the benefit of our clients and their members. Primary Responsibilities - Provides clinical support for all areas of Medical Affairs. - Review medical files and make coverage and medical necessity determinations using good judgement combined with 3rd party and proprietary medical guidelines. - Advises team nurses on appropriateness of care and services through the care continuum including hospitals, skilled nursing facilities, and home care to ensure quality, cost-efficiency and continuity of care. - Serves as medical expert for care management; reviews and evaluates cases with review nurses; ensures medical care provided meets the standards for acceptable medical care. - Reviews and resolves grievances related to medical quality of care and actively participates in the functioning of the plan’s grievance and appeals processes. - Along with the nurse supervisor and manager, identify opportunities for improvement and collaborate to enhance team performance. - Makes appropriate outreach to community and academic based treating providers wanting to discuss cases. - Identify, critique, and utilize criteria and resources such as national, state, and professional association guidelines and peer reviewed literature to support sound and objective decision making and rationales in reviews. - Collaborate with other departments, i.e. Member Services, Provider Services, Claims and Contracting, to improve performance. - Support the nurses and coordinators to improve their knowledge, independence, and understanding - Performs other duties as required by the business. - Opportunity to interact with sales and account management supporting client needs. - Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job. Essential Qualifications - Board certified MD or DO, with an excellent understanding of the utilization and case management process. - 3 years' experience working in a managed care environment supporting utilization management and case review with medical necessity determinations. - 3 + years of prior clinical practice with boards from any of a wide range of specialties so long as you are self-motivated to stay up to date on a broad range of medical services using resources. such as mcg guidelines, specialty society guidelines, Up-To-Date and other resources to analyze existing cases. - Specialty training in addition to a first board certification highly desirable. - Current, unrestricted clinical license(s). - Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer with a specialty in Orthopedic Surgery (preferred) or General Surgery. - Ability to communicate clearly and concisely, both verbally and in writing. - Knowledge of evidence-based medical guidelines (nationally recognized standards of health care), utilization management, quality improvement and other medical management functions. - Good interpersonal and communication skills to support the team approach. - Demonstrated computer skills & telephonic skills. About At Brighton Health Plan Solutions (BHPS), we’re creating something new and different in health care, and we’d love for you to be part of it. Based in New York City, BHPS is a rapidly growing, entrepreneurial health care enablement company bringing tangible innovation to the health care delivery system. Our team is committed to transforming how health care is accessed and delivered. We believe that cost, quality, and population health are optimized when people have long term relationships with their health care providers – and that’s why we’re creating new products that today do not exist anywhere in the New York/New Jersey market. With a growing labor business under the well-known MagnaCare brand, the launch of Create - a new marketplace of health systems focused on self-insured commercial health plan sponsors, and a successful Casualty business, we’re fiercely committed to positively impacting our partners. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. *We are an EEO Employer

About The Role BPHS is seeking an experienced Manager for our new Enrollment and Eligibility Department. This role will manage all operations of the Enrollment, Employer Services, Escalation, and Quality Assurance areas. The role will work closely with Employers, oversee daily communication (emails, inquiries, and calls), participate in Webinars, and ensure timeliness of daily workflow processes of enrollment and employer file validations, errors, and submissions. Primary Responsibilities •Manage the operations of the Enrollment and Eligibility Department, with emphasis on Employer Services. Analyze and manage production volumes, timeliness of data input, Employer portal reporting and workflows, and other variables to ensure optimal service to clients, employers, and caregivers. •Assist the Director/Vice President in developing strategic plans to improve operations, systemize manual processes, enhance systemic processes, evaluate and modify Enrollment and Eligibility policies and procedures to maintain compliance and service-level agreements, and promote efficient department operations. •Support Director/VP in employer, client, and vendor interactions via multi-channel functionalities (calls and emails) to effectively communicate and ensure timely responses to inquiries. •Attend employer/client/vendor meetings and perform Webinars as directed, •Work closely with Finance management to ensure all employer inquires and work hours are allocated appropriately. •Partner with IT, Operations, and Finance to prepare specifications and testing scenarios to ensure overall functionality of workflow processes and systems. •Participate in the onboarding of clients to include User Acceptance Testing. •Manage special projects and allocate resources as needed. •Make staff selections and employment decisions in accordance with established departmental procedures and Human Resources guidelines. •Develop and support ongoing communication and coordination between the Eligibility, Operations, Customer Services, IT, and Finance management teams to enhance service performance. •Perform additional duties and projects as assigned by management •Annual travel required to client conference. Essential Qualifications •Bachelor’s Degree OR 8+ years of equivalent working experience required •Minimum six (6) years of job-related experience in Health Plan management, including three (3) years of management-level experience with a high level of accountability preferred. •Ability to work alternate schedules/hours based on the business’s needs. Hours are between 9 AM and 9 PM EST, Monday through Friday. •Strong leadership skills and ability to work with all levels of staff and Health Plan management; able to make independent decisions concerning planning, scheduling, and work assignments. • Strong analytical and problem-solving skills; Ability to analyze problems and resolve issues through resolution quickly and methodically. •Knowledge of managed care, labor, and commercial carrier enrollment, and eligibility procedures, including hourly-based eligibility and waiting periods. •Prior experience with premium billing and reconciliation, knowledge of 834 eligibility files and transaction sets a plus. •Experience working with Taft Hartley Trusts. •Fluent in COBRA, FMLA, QLE, QMCSO, and other eligibility-related transactions, a plus. •Moderate proficiency with Windows PC applications, which includes the ability to learn new and complex computer system applications. •Ability to multi-task; this includes the ability to understand multiple products and multiple levels of benefits within each product. •Previous experience in quality call monitoring and performance coaching, counseling, and progressive discipline. •Excellent interpersonal and communication skills – oral, written, and listening •Ability to work remotely as needed and must have an internet service provider to support the MagnaCare remote environment. •Must meet performance standards, including attendance and punctuality. •Other duties as assigned.About At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways. JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com

About The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely. Primary Responsibilities • Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures. • Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments. • Collaborates with healthcare partners to ensure timely review of services and care. • Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. • Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards • Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate. • Triages and prioritizes cases and other assigned duties to meet required turnaround times. • Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. • Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements. • Duties as assigned. Essential Qualifications • Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment. • Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) • Must be able to work independently. • Must be detail oriented and have strong organizational and time management skills. • Adaptive to a high pace and changing environment- flexibility in assignment. • Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review. • Proficient in MCG and CMS criteria sets • Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred. • Working knowledge of URAC and NCQA. • 2+ years’ experience in a UM team within managed care setting. • 3+ years’ experience in clinical nurse setting preferred. • TPA Experience preferred. About At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

About The Role BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely. Primary Responsibilities • Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures. • Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments. • Collaborates with healthcare partners to ensure timely review of services and care. • Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed. • Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards • Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate. • Triages and prioritizes cases and other assigned duties to meet required turnaround times. • Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. • Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements. • Duties as assigned. Essential Qualifications • Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment. • Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) • Must be able to work independently. • Must be detail oriented and have strong organizational and time management skills. • Adaptive to a high pace and changing environment- flexibility in assignment. • Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review. • Proficient in MCG and CMS criteria sets • Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred. • Working knowledge of URAC and NCQA. • 2+ years’ experience in a UM team within managed care setting. • 3+ years’ experience in clinical nurse setting preferred. • TPA Experience preferred. About At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities. Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™. Company Mission Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners. Company Vision Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.